Electronic Health Records and Patient Safety

Recent studies have provided conflicting information about whether or not EHRs improve patient safety. One study, conducted by the Agency for Healthcare Research and Quality (AHRQ) and published in the Journal of Patient Safety found that fully electronic health records (their definition for fully electronic health records is records that include physician notes, nursing assessments, problem lists, medication lists, discharge summaries and provider orders are electronically generated) lead to fewer adverse events such as hospital acquired infections. However, an analysis of a large malpractice claims and suits database maintained by CRICO, an evidence-based risk management group of companies owned by the Harvard medical community, found that there were 248 malpractice cases showing serious unintended consequences from the use of EHRs.

We here at SERMO decided to poll doctors around the world to get their take on the topic. We asked: Do you think patient safety has improved, stayed the same, or worsened as a result of broader use of electronic health records. Here were the results:

The question sparked lots of conversation on the network.

Despite the mixed results from the United States doctors in the poll, most doctors who commented from America said that their EHRs were not helping improve patient safety.

A U.S. surgeon on SERMO said: “Part of the issue is that the current systems are all attempting to make medical documentation fit into the underlying coding and billing architecture. Patient care is not about checking boxes or filling out templates to assure payment. Patient care is about listening, touching and examining a fellow human being while utilizing the complex intuitive skills from our training and years of experience to come to informed decisions and make a plan of care. Any interface which distracts a doctor from that task should be rejected.”

A U.S. radiologist added, “I firmly believe that the hospital based EHR in its current state is the most significant correctable patient safety hazard in the inpatient environment. The reasons include redundant data entry points, non-standardization of reports with a copy and paste model resulting in overpopulation of the record with redundant space wasting information and making it more difficult to extract meaningful information from the record. Poorly constructed user interfaces have led to decreased clinical efficiency of all providers, encouraging minimization of interaction and reducing the volume of input of important clinical information.”

And an internal medicine doctor in the U.S. recounted this example from her practice: “I don’t see any increase in safety, just new kinds of errors. Some old errors can be prevented, such as inadvertent drug interactions. New errors are made, such as wrong drug. A family member just got discharged from the hospital, with all the printed out gibberish information, boiler-plated from the EMR. The discharge included a prescription for a medication he has never taken and doesn’t need and was not prescribed by his physician. I argued with two nurses and the pharmacist (the extra “safety” person on the discharge team) that it is not his script. They basically said, it’s in the EMR, it has to be his. He needs it. He probably has a new diagnosis. Double checked with his excellent physician. No, not prescribed.”

European doctors were more positive towards their electronic health records.

A dermatologist from Spain said, “Electronic medical records has numerous advantages. It allows you to access the patient’s medical history quickly and efficiently.”

A Spanish pediatrician added, “There are always benefits:
1. You can check the diagnosis and treatment worn by the patient without wasting time and without trying to decipher the handwriting of a colleague
2. You can add notes attention to another colleague from the patient
3. Facilitates agreement in diagnosis and treatment of different specialties
4. If you have a diagnosis on the list, you have the option to add consultation with the personnel controlling the system. Not an isolated case of this assessment, it is not enough to say that medicine is not individualized.
5. There is always the possibility of others, in history, physical examination, etc.”

Comments

There are reasons why patient care has worsened by EMR in USA, it goes down to motives.
EMR use in USA is mainly geared toward billing, coding and avoiding lawsuits, the purpose and push, although stated as being about patient safety and care, has been about “how to catch quickly and efficiently the doctors who overcharge” or “how to defend in a lawsuit by proving a lot more was done”.
If you make EMR only readable to physicians, and not to insurance companies and lawyers, doctors will write only pertinent information, decreasing the amount of gibberish proof of “I did a lot”, information which would include:
Reasons why patient was seen.
PERTINENT history.
Medications, past and present, their interactions, warnings related to medicines generated by EMR.
All past and present labs and testings.
All past diagnosis.
Any red flags ( patient is possible drug abuser, unimmunized etc)
Vital signs, Positive findings and pertinent negative findings.
Diagnosis.
Treatment done and advised.
Follow up advise and referrals.

This will aboid overtesting and medical errors.
All the unrelated details to prove that this visit qualifies to be charged at a certain level
( “Hearing was muffled, ear pinna was normal and non tender, no pre or post auricular lymph nodes palpable, external ear canal was normal without any foreign body or excessive cerumen, Tympanic memberane was red, with visible pus behind the membrane, it was dull and its motility was decreased with insufflation” replaced with
“TM red and dull”, and the billing based upon diagnosis of otitis media and not upon how many points in the system were examined and documented, and what treatment and testing done. )
What to do about the legal issues and protection from lawsuits? Sue the lawyer who brings a frivolous lawsuit, sue the judge whose judgment is overturned in an appeal. Let them feel what doctors feel when treating a patient.